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HomeMy WebLinkAboutMiscellaneous - 112 MILLPOND 4/30/2018 112 MILLPOND 210/095.A-0112-0000.0 4 2 Date... ............................. NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING ti This certifies that ... . . .......... .......................... . .............................. has permission to perform .......... ......... wiring in the building of........... ..................................................... r ......./.�... ..... ..................... .North Andover,Mas Fee..X5............ Lic.No.0.�79-?,e..... ............. ... G� TICAL INSPE R Check t, Commonwealth of MassachusettsFe fficial use only Department of Fire Services %�j / y— BOARD OF FIRE PREVENTION REGULATIONS Fee Checkedp ® ave blank APPLICATION FOR PERMIT' TO PERFORM ELECTRICAL All work to be performed in accordance with the Massachusetts Electrical Code(MEC 52 00 WORK (PLEASE PRINT EV NK OR TYPE ALL INFORMATION Citgo or Town of- NORTE[ANDOVER ) Date: To.the Insp ctor of By this application the undersigned gives notice of his or her intention to perfoim the electrical work described below. Location(Street&Number) Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building EJNO E] (Check Appropriate Box) Utility Authorization No. Existing Service Amps ­-L—Volts Overhead ❑ Undgrd❑ No.of Meters Newer Amps _L_Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and.Ampacity Location and Na , •e of Proposed lec4•ical Work: Com letion of the followin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Cell:Sus No.of • D.(Paddle}Fans To Ntal No.of Luminaire Outlets Transformers rA a.of Hot Tubs No.of Luminaires Generators KVA Above Swimming Pool ❑ �- o.o mergency Ig g --, d' nd. ❑ Batter Units No.of Receptacle Outlets No.of Oil Burners FL�F A- 'P1►IS No.of Switches No.'of ZonesNo,of Gas Burners No..of Detection and No,of Ranges Initiating Devices . No.of Air Cond. Total No.of Waste Disposers Heat Pump Number Tons No.of Alerting Devices Totals: Tons KW _ No.of Self-Contained _._......_......._._. No.of DishwashersDetection/Alertin Devices Space/Area Heating KWLocal❑ Municipal No.of Dryers Connection ❑ Other �' Heating Appliances KW Security Systems:* No.of Water No.of No.of Devices or Equivalent Heaters KW No.of Data Wiring: Si s Ballasts. No.of Dvices or E uivaIent No.Hydromassage Bathtubs No.of MotorsTotal HP Telecommunications Wiring; OTHER: No,of Devices or E uivalent i Attach additional detail if desired,or as required by the Inspector of Wires Estimated Value of Electrical Work: .� Work to Start: (When required by municipal policy_) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee.provides proof of liability insurance including`°completed operation"coverage or its substantial a uivale undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. nt The CHECK ONE: INSURANCE ❑ BOND ❑ OTHER I certify,under the p •n and penalti o er u that the in❑fo(mpation on this a licatio fP J r/1' FIRM NAME: GCIb� PP n is true and complete. Licensee: LIC.NO.: (If applicable, enter"exem Signature the lice e LIC.N Address: umbel•1' .) O..�j—Q e,( / Bus.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires DePartanent of ublic Safety S License: Alt.Tel.No.:�-fit Z S/ OWNER'S INSURANCE WAIVER; I am aware that the Licensee does not have 1the liability Lic.No. urance required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ er coverage❑owner's glent Owner/Agent Signature Telephone No. PERMIT ELECTRICAL PERMT NO. ELECTRICAL INSPECTOR-DOUG SMALL REPORT: 1.ROUGH INSPECTION: Passed—j ) Failed—[ ] Re-inspection requiredf($50.00)-j ] Inspectors' comments: •yY _ (Inspectors'Signature-no initials) Date t2.FIDNALINSPECTION:d—[ Failed—j ] Re-inspection required($50.00)=j I ctors'comments: (Inspectors'Signature-no initials) Date •µ'� 3 rUNDTR, OUt+ I INSPECTIDN;iz r ,, r 7 �° y`S*` � . r ,•` , 'Passed—j ] Failed- , ] Re-inspection required($50.00)-j ] Inspectors' comments: Y A (Inspectors'Signature-no initials) Date 4.INSPECTION—SERVICE: DATE CAILLE'D NA'T'IONAL GRID: NAS: Passed—j ] Failed—j ] Re-inspection required($50.00)-j ] Inspectors' comments: (Inspectors'Signature-no initials) Date 5.INSPECTION-OTHER: Passed—j I Failed—j ] Re-inspection requ' ed($50.00)-j I Inspectors' comments: �-> • , e� (Inspectors'Signature--no initials) Date • y y\ Dd6k— 'AGS ARE TO BE FILLED.ORMAN ` •,' ��� :I' ` ° 'w ' OSIE `" A TO BE INSPECTED IS NOT •,Y+.'4^�° ` ' '�' ACCESSIBLE AND.ARE-INSPECTION OF$50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mrass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual); C .2 BCGs�� Address: City/State/Zip: /y�2(,J �Q s'(�Ge-feL /U9- Phone#: [Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): , , Jemployees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.& am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub=contractors have working for me in any capacity. workers'comp,insurance. 8. ❑Demolition [No workers comp. insurance 5. 9• ❑Building addition ' P ❑ We are a corporation and its required.] officers have exercised their 10 'Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no insurance required.] ' employees- NO workers, 12-E]Roof repairs comp.insurance required.] 13-El Other izny applicant that checks box 4l must also fJl out tae section below showin­::heir wort: 011 Policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contra ct rs must submit new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. an employer that is providing workers'compensa infoo rmation. tion insurance for my employees Below is the policy and job site Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: ------------ Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement ma be forward Investigations of the DIA for insurance coverage verification. y ed to the Office of I do hereby certify under the pains and penalties of perjury that the information provided above is •ue and irect Signature: Date.: Phone#: •- J Official use only. Do not Pyrite in this area, to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): , L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Person• Phone#: i • ', a .. ,- -_ +re-•-.�-- � Vit. COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS AS A.REG JOURNEYMAN ELECTRI;CIA ISSUES.THE ABOVE LICENSE TO: ANTHONY R SCANNE.LLI JR 4 WE ST. ST MEDF.O;RD . MA 02:1:5;5-43,2..5. 37 B 07/31/13 864480 t { t is G -•� '� OP ID:JR CERTIFICATE OF LIABILITY INSURANCE DA 06/9011D YYm THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorseme s. CONTACT PRODUCER 603-357-0188 NAME" Sammon&Wojenski Ins,Inc. 603-357-1331 PHONE FAx The insurance Center A FirthNe° 55 Main Street Suite A 1°O1c E Keene,NH 03431 ERID,ADVAN-3 IN$U S)AFFORDING COVERAGE NAIC# INSURED Advanced Telecom INSURERA:Peerless Insurance Company 24198 Construction Co LLC INSURERS: 205 Hubbard Pond Road New Ipswich,NH 03071 INSURERC INSURER D: INSURER E; INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADD BUSH TYPE OF INSURANCE POLICY NUMBER M POLICY F LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000.00 A X DAMAGE TO RENTED COMMERCIALGENERALLIABILITY CBP8774680 06124/10 08/24!11 PREMISES Eeaccunerroe $ 100,00 CLAIMS-MADE FXI OCCUR MED EXP(A.ny one person) $ _ 5,00 PERSONAL&ADV INJURY $ 1,000.00 GENERAL AGGREGATE $ 2,008.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,00 X POLICY PRO- FISECT F]LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00 A ANYAUTO BAS776798 06/24/10 OW24111 (Easwidmtl) BODILY INJURYPer person)( pe ) $ --..... _ ALL OWNED AUTOS BODILYINJURY(Per acaderd) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIREDAUTO$ (Pereodderd) X NON-OWNEDAUTOS $ )( BUSINESS AUTO BAS776998 06124110 06124111 $ )( UMBRELLALIAB X OCCUR EACH OCCURRENCE $ _ 5,000,00 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,00 A CU8777198 06124110 06124111 DEDUCTIBLE $ X RETENTION 10,000 I S WORKERS COMPENSATIONIMM WC STATU X 0TH AND A ANY ROPRI QWPARTNERfEXECLRIVE Y!N C8776498 06124/10 06124111 E_L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUQED? ❑Y N/A (Mandatory In NH) NH MA RI E.L.DISEASE-EA EMPLOYEE $ 1,000,0 Hilpes describe under j DESLIRIPnoN OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 I DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLE$(Attach ACORD 101,Additional Remedes Schedule,K more specs K r"Wrad) s Michael Kinsinger and David Rapa,members,are excluded from workers compensation. Property location:112 Mill Pond,North Andover MA CERTIFICATE HOLDER CANCELLATION NORTHA4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF NORTH ANDOVER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ATTN:PETER MURPHY ELECTRICAL INSPECTOR AUTHORIZED REPRESENTATIVE 1600 OSGOOD STREET NORTH ANDOVER,MA 01845 ' ®1988 2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD r a", � r � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN (Print or Type) NORTH ANDOVER /Mass. Date 9 building Location J/�/ /l��t Permit # /4'7 ' -� Owners Name RIX,16110— • New 77 Renovation Replacement Plans Submitted D FI XTUPEIS rn _. sA Q N cc .O =2N S F Ul m f' �_ � n' F Q r '� to N I- W W O 0. O W t- •., t- N 4 CC N d w 4 z O �, W N cc W Z V 07 ys •t Q 1, D W W to a n' LC Q Q W W F" z ro Q o !� Z J F' 2 W W O > U. t- V J l.. W Q yr > C W O Z 4 G Q d O O uJ o W 1� ct z o ra o SUR,—BSMT. t ! BASEMENT I I ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR TTH FLOOR RTH FLOOR (Print or Type) Check e: Certificate Installing Company Name 611-7Corp. Address � /y A, - 1 = Partner. Firm/Co. Business Telephone: 27 V- O/?�l Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of insurance covers e by checking the appropriate box: Liability insurance policy Other type of indemnity F Bond Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner Agent I hereby certify that all of the details and information 1 have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Weed for this application will-be in compliance with an pertinent provisions of the Massachusetts state Gas Code and Chapter 142 of the General haws. By TYPE LICENSE: Plumber Title sfitter Sign Eur of Licensed City/Town: 71Master Plumber or Gasfitter Journeyman !JV�6, APPROVED (OFFicE USE ONLY) — Lidee Number t � � 1 j Date.!" J l „ORTti TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACHUSEt This certifies that . . .`. . . .1. . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . .P/. . . . . . . . . . . . . . . . . . . . . . in the buildings of , .". . :.: .. .!. . . . . . . . . . . . . . . . at . '.:'.'. . . ::< . . r.!. . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. X . . . . . . Lic. No.. . . . .. . .'. . 12/08/94 06:4315.00 PAID` GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File !G Date- TOWN OF NORTH ANDOVER o•�,�ao .•� o p PERMIT FOR WIRING SSACMUSEt This certifies that ........h.:�..IJ y...... ......�4.�..!".y................... has permission to perform . �. `� ��� 'n-c wiring in the building of............................. P(� ��!..� ........... ..... .... .. at......._....�..�!:....... ..�J.l...6..j..........�............ I�iorth Andover-), dass!�' Fee.... ' ....... Lic.No�/..........f �.�'�?�...!� . ....... ..................... ELECTRICAL INSPECTOR Check # 45 'j 8 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. y r BOARD OF FIRE PREVENTION Occupancy and Fee Checked [Rev.11/991 (leave blank) REGULATIONS APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC).527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: S ,y'0.3 City or Town of: {VO'rA- lJ rV1-A-- To the Inspector of res: By this application the undersigned gives notice of his.or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant ti [l��fGe�� Telephone No. (Q so,_ Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: &tZ�JAt� q0 �P I `J s' i Com letian of thefollcwing table may be waived b the Ins ector o Wires. No.o*f Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA Above In- No.of Einer enc Lighting No.of Lighting Fixtures Swhnming Pool ❑ ❑ g y g g rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tom No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Tot Detection/Alerting Devices ab: No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No..if Dryers Heating Appliances KW Security Systems: No.of Devices or Equivalent No.of No.of Data Wiring: No.of Water K- sigm ii"sis iia. .,s... c+e 0r E4 e'nitciii Heaters No.Hydromassage Bathtubs No.of Motors Total HP Telecowtiumn"trons Wifliik No of Devices or E quivAept" .: OTHER: Attach additional detail ij'desired,or as required by the Inspector 6 ifirer" INSURANCE COVERAGE: Unless waived by the owner:no permit for the performance of electrical werk may issue unless the licensee provides prop)f of liability insurance including"completed operation"coverage or its suhutantial equivalent. The undersigned certifies that such coverage is in force,and has wd ibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 19 BOND ❑ OTHER ❑ (Specify:) ON FILE _ l (Expiration Date) Estimated Value of Electrical Work: — r-� (When required by municipal policy.) Work to Start: rJ" V Insbe requested in accordance with MEC Rule 10,and upon completion. I certify,under the pams an en o perjury,that the information on this application is hue and complete. FIRM NAME: LIC.NO.: Licensee: Kelly M.Casev, Signature �.&A LIC.NO.: 37200 If app .lt i Bus Tel:-No.: 978-697-4453 Address: ✓�V /� �1�� 3 71L�t!�r L� �l�d�' Alt.Teti No.:' OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required 6y'pa:iv. By nay signature'beiodr.' I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PEIZLII7 FEE: l�j, "